Esophageal Disorders Flashcards
What levels does the esophagus extend?
C VI to T XI.
What two organs overlay the esophagus?
Left main bronchus & aortic arch.
Why is it easy for disease to spread from the esophagus?
No serous layer separating it from other organs.
Pericardium only separates it from the heart; can also spread to bronchus.
What can compress the esophagus?
Aorta in a thoracic aortic aneurysm.
Also an enlarged heart in congestive heart failure.
What vascular anomalies can compress the esophagus?
Double aortic arch can form a ring around it; usually Peds w/ sx of stridor.
Carotids can wrap around the esophagus.
A patient presents with dysphagia. A barium swallow shows the carotid artery wrapped around the esophagus. What is the diagnosis?
Dysphagia lusoria.
Tx: surgery
What makes up the upper esophageal sphincter?
Inferior constrictor, cricopharyngeus muscle, proximal esophagus.
What is the function of the UES?
Prevents regurgitation of food into the pharynx.
Prevents air from entering esophagus.
What is the function of the LES?
Creates a pressure gradient in the distal esophagus. Opens when someone swallows so that the stomach can receive the food bolus and then closes to prevent regurgitation.
Z Line
Squamous-Columnar transitional zone b/t the esophagus and stomach. Important for dx of Barrett’s, GERD.
A 60 y/o male presents with halitosis and regurgitation of chewed food particles. What test do you order?
Barium swallow.
What is a proximal esophageal diverticulum called?
Zenker’s diverticulum (of the proximal esophagus posteriorly into Killian’s Dehissance).
When patient lays down, food trapped in the diverticulum is regurgitated. Because it’s been in the pouch for a long period, it’s not broken down and can cause bad breath.
What is the name of a distal esophageal diverticulum?
Epiphrenic diverticulum.
Sx of Epiphrenic Diverticulum
Patient lays down and they regurgitate a large amount of food.
Associated with Achlasia.
Esophageal Webs
Mucosal outpocketing that causes obstruction.
Esophogeal Rings
Muscular; spastic and resolve on their own without interfering with swallowing.
A 35 y/o male presents to the ER complaining of chest pain just 30 minutes after eating at Longhorn Steakhouse. He is spitting a lot of saliva into a cup when you go to examine him. Negative hx of cardiac symptoms and no findings on exam. What is your diagnosis?
Schatzki’s Ring (Web).
An outpocketing of the mucosa of the distal esophagus that prevents bolus from entering the stomach.
Tx: surgical removal
A 40 y/o female presents with dysphagia. A hematocrit shows she is also anemic. What is your diagnosis?
Plummer-Vincent Syndrome (proximal esophageal web).
A patient with uncontrolled Diabetes presents to your practice complaining of burning with swallowing (odynophagia). On exam, there are white, plaque-like formations on the esophagus. A barium swallow shows a “shaggy” esophagus. What is your diagnosis?
Candida infection.
A cancer patient presents with odynophagia. A barium swallow shows vesicles in the esophagus and a biopsy reveals Cowdry Bodies. What is your diagnosis?
Viral HSV infection reactivated.
An AIDs patient presents with odynophagia. Biopsy reveals inclusion bodies in fibroblasts. What is your diagnosis?
Reactivation of CMV.
Tx: acyclovir
A patient presents with dysphagia and a mass is viewed under the scope. On X-Ray, a smooth indentation is seen. What is your initial diagnosis?
Benign lyomymoma.
Intralumenal between mucosa and submucosa.
Tx: surgical removal
A patient presents with dysphagia and odynophagia simultaneously. She admits to dry-swallowing her anxiety medication three days prior because she was in a hurry. What is the diagnosis and etiology?
Esophageal stricture.
Normally, drinking water induces the relaxation of the LES, which prepares the stomach to accept a pill. When people dry-swallow, the esophageal sphincter doesn’t open and the pill gets lodged within the esophagus. The pill begins to dissolve and burns the esophagus.
A 2 y/o patient presents after ingesting toilet cleaner (A caustic substance) with burns on his mouth. What is your plan of action?
Endoscopy to see how far the damage has gone. Remember, the esophagus is thin and has no protective layer; damage her can easily spread to the heart through the pericardium.
What portion of the GI tract do strong acids affect primarily?
Stomach.
Battery acid, toilet bowl cleaner, etc.
What portion of the GI tract do strong bases affect?
Esophagus.
Drain cleaners.
An attending shows you an X-Ray of a patient whose stomach appears to be pushing into the esophagu and asks you for a diagnosis. What do you say?
Sliding hiatal hernia.
An attending shows you an X-Ray of a patient whose stomach appears to be pushing up into the thoracic cavity (with the esophagalgastral junction intact) and asks for a diagnosis. What do you say?
Paraesophageal hernia.
Can lead to volvulus.
50% mortality even when treated.
A 68 y/o male presents with acute emesis and chest pain. X-ray shows a pleural effusion. What are you concerned of?
Esophageal rupture, which is fatal within 24 hours.
Tx: surgical repair.
A patient presents to the ER throwing up bright red blood, but quickly recovers a few hours later. What is the diagnosis you write on the discharge paperwork?
Mallory Weiss Tear at the esophagastral junction.
A four year old presents to the ER after swallowing 27 cents. What is your plan of action?
Wait 7 hours to see if the quarter and pennies have passed into the stomach. If not, go in to surgically remove them.
What is GERD?
Gastroesophogeal reflux disease.
A pathological frequency of reflux of gastrointestinal content into the esophagus.
What is Heartburn?
A SYMPTOM of GERD.
Burning retrosternal pain due to exposure of the esophagus to acid for a prolonged period of time.
What is Esophagitis?
Endoscopic or histological demonstration of inflammation of the esophageal mucosa.
What is erosive esophagitis?
Erosion of the esophageal lining; damages the mucosa causing redness, bleeding, and ulcers.
How many adults have heartburn at least once a month?
44%.
How many adults have daily GERD symptoms?
7%.
A GI attending asks you to quickly list the symptoms of GERD at 5 a.m. rounds. What do you say?
Chest/epigastric pain, worse on lying down/bending, worse after meals, worse after eating at night and lying down with stomach full.
What is the most common GI Disease?
GERD.
Erosive esophagitis LA Grade A
One or more mucosal breaks no longer than 5 mm, none of which extends between the tops of two mucosal folds.
Erosive esophagitis LA Grade B
One or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds.
Erosive Esophagitis LA Grade C
One or more mucosal breaks that extend between the tops of two or more mucosal folds but together involve less than 75% of the esophageal circumference.
Erosive Esophagitis LA Grade D
One or more mucosal breaks that involve at least 75% of the esophageal circumference.
What are the major factors of the Pathophysiology of GERD?
Decreased LES resistance to prevent regurgitation of stomach contents (due to weak LES, hiatal hernia)
Disturbed LES function (inappropriate transient relaxation causes it to remain open longer)
Overwhelmed LES due to increase intraabdominal pressure (i.e. pregnancy)
What are exacerbating factors of GERD?
Decreased esophageal clearance, increased intragastric acidity/volume, smoking/alohol use, coffee, drugs (calcium antagonis, beta adrenergics, anticholinergics)
GERD results from exposure of the esophageal mucosa to refluxed gastric contents.
In most patients, exposure to refluxate is greater than normal.
What conditions can cause delayed esophageal clearance?
Uncontrolled diabetes, people on lots of meds.
What are causes of defective esophageal clearance?
Ineffective peristalsis
Reduced salivary secretion
Reduced secretion from esophageal glands
LES dysfunction
Reduction in LES basal/resting tone
Inappropriate and prolonged transient relaxations
How can a hiatal hernia cause GERD?
May trap a reservoir of gastric contents above the diapragm, increasing reflux.
It can also compromise LES funtion.
What conditions can increase intra-abdominal pressure?
Pregnancy, obesity, bending, straining, coughing, tight clothes.
How can delayed gastric emptying be involved with GERD?
May result in an increase in the volume of gastric contents available for reflux back into esophagus.
Symptoms of GERD
Heartburn & Acid regurgitation
Symptoms occur after meals and are triggered by large meals, spicy/acidic foods, bending/stooping/straining
A 50 y/o Caucasian male presents with symptoms of GERD for 3 years duration. On biopsy, there was columnarization of the squamous cells of the esophagus. Symtoms worse at night. Bleeding, ulcer, stricture are associated. Diagnosis?
Barrett’s esophagus.
What cancer is associated with Barrett’s Esophagus?
Adenocarcinoma.
What is endoscapy used for in GERD?
To identify Barrett’s
To diagnose erosive grade/complications
Normal doesn’t rule out GERD
What is Ambulatory Reflux Monitoring?
Helps confirm GERD in patients with persistent symptoms but no mucosal damage, especially when acid suppression fails. Done while patient is on therapy
BRAVO
“blue tooth” of esophagus; measures acidic environment.
A form of Ambulatory Reflux monitoring to dx GERD.
What is the gold standard treatment for GERD?
Acid suppression using Proton Pump inhibitors.
What are some lifestyle measures that can be used to treat GERD?
Elevate the head of the bed, decrease fat intake, avoid lying down for 3 hours after eating, stop smoking, lose weight.
Antacids for GERD
Prompt but temporary relief of symptoms.
Prokinetics
Improvement of symptoms in mild GERD.
Because they affect smooth muscles, can have undesirable side effects like twitching, nervousness. Must STOP DRUG to stop them. Becomes permanent if not.
H2RAs in treating GERD
Relief of heartburn and can heal erosive esophagitis.
Why are H2RAs not used to treat GERD often in the U.S.?
Because the doses are frequent and there’s low patient compliance.
Why are Proton Pump Inhibitors the most effective treatment for GERD?
Better for symptom resolution and healing of erosive esophagitis. Dosage is once daily.
Careful if patients ask about OTC instead because dosing isn’t the same.
What is the mainstay of therapy to treat GERD?
Acid suppression, msotly using PPI’s.
Surgery for GERD
A maintenance option for pt’s with well-documented GERD. Effictive in up to 90% of patients, but not a permanent treatment. Starts to decline 5-10 years after procedure and must go back on PPIs. However the PPI treatment is more effective than before surgery.
Nissen & Toupet.
Why wasthe Lower Esophageal Sphincter Augementation via endoscopic implantation of Ethylene Vinyl Alcohol not widely accepted?
People were injecting through the esophagus and into the pericardium…led to death.
LESA
Re-establishes functionality of LES to reduce or eliminate need for meds for GERD.
What is the best way to dx GERD?
Well-taken history and an empirical therapy. Endoscopy is used to see how complicated the disease is and if Barrett’s is a risk.
Laryngopharyngeal Reflux Disease
Larynx has no intrinsic defense or clearance mechanism, so it can be exposed to acid exposure.
Findings in Laryngopharyngeal Reflux
Arytenoid/interarytenoid changes, granuloma, cobblestone appearance. Sx persist after GERD is treated.
COULD be aused by allergy, asthma, etc.
Progressive Symptoms of Laryngopharyngeal Reflux
Postnasal drip, laryngeal irritation, throat clearing/chronic cough, voice changes (tone, pitch, tenor)
A patient presents with a past hx of GERD. He is currently on Proton Pump Inhibitors, but the symptoms persist. His voice is gravelly and he clears his throat a lot during the conversation. Admits to post-nasal drip. Denies allergies and smoking. He is retired. What is your diagnosis?
Laryngopharyngeal Reflux Disease.
How do you diagnose Laryngopharyngeal Reflux Disease?
Do a pH study while the patient is on PPIs. If acidic, probably positive.
Rehab for Laryngopharyngeal Reflux
Voice training - quiet voice
Fluids to prevent viscous secretions
Lemon drops to stimulate salivation
What is unique about the musculature of the esophagus?
There are two layers of muscle: outer longitudinal and inner circular.
It contains both smooth and striated muscle.
What conditions can lead to oropharyngeal dysphagia?
Obstructing lesions (tumors, osteophytes)
Neurologic disorders (CN lesions, CNS lesions)
Skeletal muscle disorders (inflammatory myopathies, muscular dystorphies)
Neuromuscular Transmission Disorders (Myasthenia gravis)
Cricopharyngeus dysfunction
Cricopharyngeal dysfunction
Appears as indentation in the esophagus on swallowing on barium swallow.
Normal Motility of the Esophagus
Contraction of musculature as bolus moves down esophagus followed by relaxation as bolus passes.
The LES contracts to protect regurgitation and then relaxes again once the bolus moves forward.
Achalasia
Caused by degeneration of the dorsal motor nucleus and loss of ganglion ells on distal esophagus leading to incomplete relaxation of the LES. This prevents food from passing as easily into the stomach and leads to aparistalsis.
Motility in Achalasia
The LES is hypertensive and undergoes incomplete relaxation.
There is simultaneous, spontaneous contraction of musculature of the esophagus.
On barium swallow, there is often a meniscus sign (air bubble; no stomach visible).
Which type of achalasia is most responsive to treatment?
Type 2.
What is a CCK Octapeptide test?
Normally, CCK causes a decrease in LES pressure. In pts with achalasia, it causes a paradoxical increase in pressure.
A 35 y/o female presents with heartburn, non-cardiac chest pain, persistent cough, and dysphagia of both solids and liquids simultaneously. Patient also has difficulty belching. On barium swallow, a meniscus sign is seen and food debris is collected in the esophagus. What is your diagnosis?
Achalasia.
What finding on barium swallow is indicative of Achalasia?
Bird-breaking at the distal end of the esophagus because the LES fails to relax.
Treatment of Achalasia
Nitrates, calcium channel blockers, botulinum toxin.
Dilation of the esophagus.
Myotomy.
Scleroderma
Connective tissue disorder characterized by vascular obliteration and fibrosis in smooth muscle.
GI manifestation of a systemic condition is a weak LES.
GI Symptoms of Scleroderma
Poor esophageal contractility and delayed gastric emptying. Often increases the risk of reflux.
Contractility of Esophagus in Scleroderma
Hypotensive.
CREST Syndrome is related to Scleroderma. What are the symptoms?
Calcium deposits in connective tissue
Raynaud’s phenonmenon (narrowing of vessels in hands or feet)
Esophageal narrowing
Sclerydactyly (thick, tight skin on hands)
Telangiiectasias (red spots on face/hands)
What is seen in Scleroderma on barium swallow?
No bird-beaking as in achalasia; just slow motility.
Eosinophilic Esophagitis
Adults present with food impaction; especially in young people.
Dx: confirmed by endoscopy; must see 15 eosinophils/high power field and exclude other causes. 4 biopsies from 2 separate areas.
Do biopsy even if endoscopic appearance is normal.
Proton Pump Inhibitors and Eosinophilic Esophagitis
Many eosinophils are responsive.
Trial of PPI before EoE dx for 8 weeks.
Reassess endoscopically or symptomatically.
Endoscopic Features of Eosinophilic Esophagitis
Mucosal pallor (edema, loss of vascularity) Furrows Exudates (plaques) Stricture Fix rings
Furrowing
Longitudinal dark lines extending up the esophagus.
Rings of Esophagus in EoE
Trachealization (concentric rings)
Treatment of Eosinophilic Esophagitis
Steroids; swallowed work well.
Fluticasone, Budesonide.
Endoscopic reassessment in 3-6 months looking for < 15 eosinophils/high power field.
If steroids are ineffective in the treatment of Eosinophilic Esophagitis, what is the next step?
Modify the diet, testing for allergies and removing common food allergens (wheat, soy, milk nuts, eggs, seafood)
Symptoms of Esophageal Motility Disorders
Chest pain & dysphagia.
A patient presents with dysphagia and non-cardiac chest pain. Spastic waves with stacking of peristaltic waves are seen on barium swallow What is your diagnosis?
Diffuse Esophageal spasm.
You decide to perform a barium swallow on a patient with dysphagia and mild non-cardiac chest pain. There are several areas of constriction. High amplitude, spontaneous contractions are seen electrically. What is your diagnosis?
Nutcracker esophagus.
What is seen electrically in Hypertensive LES?
An exaggerated post-relaxation contraction of the LES
Chest Pain Differential
Cardiac or non-cardiac. If patients present with chest pain, MUST do a cardio workup first.
May be an esophageal motility problem or even reflux.
What is the most common esophageal motility disorder?
Nutcracker esophagus with diffuse spasms on BS.
How is non-cardiac chest pain managed?
Anti-reflux therapy (PPIs), smooth muscle relaxants, esophageal dilation.
